How Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) Work: Cross-Disciplinary Perspectives

Abstract

Evidence from multiple lines of research supports the effectiveness and practical importance of Alcoholics Anonymous and Narcotics Anonymous. Conference presenters discussed the relationship between 12-Step participation and abstinence among various populations, including adolescents, women, and urban drug users. Insight from the arts and humanities placed empirical findings in a holistic context.

This report summarizes the proceedings of a conference held on September 25, 2009, in Ann Arbor, Michigan, titled, “How Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) Work: Cross-disciplinary Perspectives.” The conference was sponsored by the University of Michigan's Substance Abuse Research Center, Addiction Research Center, Depression Center, Department of Psychology, and School of Social Work. The conference presented empirical evidence of the effectiveness of AA and NA and provided perspectives through the additional lenses of historical context and philosophical inquiry. The presentations and presenters were as follows: (1) Sarah Zemore, PhD: Alcoholics Anonymous Effectiveness: Faith Meets Science; (2) Alexandre Laudet, PhD: Twelve-Step Participation Among Polydrug Users: Longitudinal Patterns, Effectiveness, and (Some) Lessons Learned; (3) William White, MA: The Varieties of Recovery Experience: AA, NA and the Diversification of Pathways and Styles of Long-Term Addiction Recovery; (4) John Kelly, PhD: From iPod to iGod: are 12-Step Groups Hip Enough for Adolescents?; and (5) Elizabeth A. R. Robinson, PhD: Alcoholics' Perceptions of AA's Helpfulness: Qualitative Responses and Association with Drinking Outcomes. Presentations were followed by a panel discussion. Panelists included the five presenters as well as a presentation by Ernest Kurtz, PhD, and a summary of the presentations by Stephen Strobbe, PhD. The current state of social science research on AA and NA's effectiveness was presented. This article summarizes the conference presentations including recommendations for treatment and further research. The original presentations can be streamed online at http://sitemaker.umich.edu/umsarc/How_AA_and_NA_Work.

AA Effectiveness—Evaluating the Evidence

Zemore presented Kaskutas' (2009) article, “Alcoholics Anonymous Effectiveness: Faith Meets Science.” Noting diverging conclusions about AA's effectiveness in the literature, Zemore presented Kaskutas' approach to evaluating the evidence about AA, highlighting many categories of evidence. She took as the framework for evaluating the research 6 formal criteria for establishing causation described in Mausner and Kramer (1985): (1) strength of the association, (2) dose-response relationship, (3) consistency of the association, (4) correct temporal ordering, (5) specificity of the association, and (6) coherence with existing information. Strong evidence for Criteria 1– 4 and 6 was presented. Evidence for Criterion 5 was reported as mixed. Emphasis was made on the totality of the evidence in favor of AA as a causal agent of abstinence. This quote from the 2009 article summarizes the findings:

… the evidence for AA effectiveness is strong: rates of abstinence are approximately twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are evident at AA meetings and through the AA steps and fellowship. (criteria 6, plausibility). (Kaskutas, 2009, p. 155)

12 Steps, Drugs, and Urban Populations

Laudet's greatest contribution to the field made itself apparent by the fourth slide of her PowerPoint presentation. In an area of research that has been criticized by drawing too heavily on White male samples, Laudet surveyed a sample of individuals who live in New York City's inner city: people of color who have long, severe histories of crack and/or heroin addiction. Laudet reported findings from two National Institutes of Health-funded studies designed to elucidate patterns and predictors of long-term recovery (http://www.ndri.org/ctrs/cstar/pathways.html) and predictors and effectiveness of 12-Step participation following outpatient treatment (http://www.ndri.org/ctrs/cstar/aftercare.html).

First, Laudet examined the role of 12-Step affiliation—meeting attendance and involvement in 12-Step suggested activities—as predictors of abstinence sustained continuously over one or more years. Attending 12-Step meetings, considering one's self a member of a 12-Step fellowship, and working the steps at baseline were predictive of sustained abstinence over one year. Continuous 12-Step attendance (weekly or more frequent) over 3 years predicted sustained abstinence over three years. Across recovery stages, individuals were 4.1 to 8.6 times more likely to achieve sustained abstinence by continuous 12-Step meeting attendance and involvement.

A series of analyses identified which specific elements of 12-Step involvement were responsible for positive outcomes and whether these elements varied by gender. Women were significantly more likely than men to sustain abstinence over 3 years although genders did not differ significantly at baseline. Twelve-Step involvement, that is, involvement in such activities as having a sponsor, doing service, reading recovery literature and contacting other 12-Step members outside of meetings, was predictive of continuously sustained abstinence over 3 years for women but not for men. Several specific 12-Step activities were predictive of sustained abstinence over 3 years for women, but not for men, including socializing with 12-Step members, reading 12-Step literature, contacting members outside of meetings, step work, identifying as a 12-Step member, and having a sponsor. For men only, being a sponsor was predictive of sustained abstinence over 3 years. For men and women, doing service and having a home group was predictive of sustained abstinence over 3 years. Laudet discussed how some of these activities can be translated outside of the 12-Step context to benefit individuals who choose not to participate in 12-Step groups.

Rates of attrition from AA and NA were examined. Among those who started NA and AA attendance, the majority (85% and 91%, respectively) stopped NA and AA attendance for a month or longer. Data support the idea that the 12-Step career, like the treatment career, consists of multiple interrupted episodes of participation. In general, 12-Step attendance and involvement decrease over time.

Given the effectiveness of 12-Step participation and the observation that attrition rates are high, Laudet has also investigated attitudes toward AA and NA among individuals in an outpatient treatment program. Clients rated the importance of 12-Step programs to recovery 8.7 on a 10-point scale with high scores indicating higher importance. Clients rated the helpfulness of 12-Step programs 8.02 on a 10-point scale with high scores indicating high levels of helpfulness. Clients stated that their top two reasons for attending AA and NA were to (1) promote recovery/sobriety and to (2) find support, acceptance, and friendship.

Two sides of an equation were presented: reasons given for leaving AA and NA mirror reasons related to relapse. Among those Laudet surveyed, the reasons for leaving 12-Step programs included using drugs/alcohol and not being ready to stop (27% with regard to NA, 33% with regard to AA) and not needing these programs or wanting to recover “on my own” (25% for NA). The lessons learned from relapse included reminders to stay focused on recovery and stay motivated (42%) and to seek help and support (44%). Therefore, treatment can target the issues highlighted by this mirror image by working to enhance motivation and helping individuals to seek and accept support.

Finally, Laudet presented data from a quasi-experimental study on the influence of holding a 12-Step meeting on-site at a treatment program on clients' 12-Step participation and substance use outcomes after treatment. Participants were drawn from two similar treatment programs with the key difference between them being that one held a weekly 12-Step meeting on-site and the other one did not. Participants did not differ significantly across programs in terms of substance use, treatment, or 12-Step history. Data showed that clients who attended the treatment program with the on-site meeting attended significantly more 12-Step meetings in the year after discharge and had significantly greater rates of drug abstinence over the post treatment year than did clients who attended the program where no 12-Step meeting was held on-site. To read more about this research, please see Laudet (2008a, 2008b).

Is AA Effective for Adolescents?

Kelly spoke about the experience and outcomes of adolescents in 12-Step programs. Although it is a common practice for treatment facilities to refer teens to 12-Step programs, the effectiveness of 12-Step programs with this population is not often studied. He presented findings from his longitudinal study of teens in AA who were followed for 8 years. Study aims included (1) describing rates and predictors of participation in AA/NA over 8 years following inpatient treatment, (2) examining the relationship between early and ongoing AA/NA participation and substance use outcomes, and (3) exploring dose-response thresholds of AA/NA attendance and outcome. The sample was composed of 166 male and female teens (average age 16) who had completed an inpatient treatment program.

Findings indicated that gender predicted outcome. At 4-, 6-, and 8-year follow-up, girls (40% of the sample) had more abstinent days than boys. If respondents felt they could moderate their use of drugs and alcohol, rather than stop completely, this predicted less abstinence at each follow-up occasion.

In the study sample, 12-Step participation was common and intensive after inpatient treatment but fell off over time. However, despite declining attendance, early posttreatment attendance, even in relatively small amounts, predicted long-term helpful outcomes. Specifically, it was found that for every meeting attended there was a subsequent gain of approximately 2 days of abstinence. Although the drop in attendance was noted, consistent attendance over time predicted favorable outcomes.

As with adult populations, addiction severity predicted AA/NA attendance, with greater severity associated with greater attendance. In the first 3 months of AA/NA attendance, adolescents fared better if they attended groups largely populated by teens, but in the subsequent 3 months, adolescents fared better if meetings they attended were populated by an even mix of teens and adults. It was found that three or more AA/NA meetings per week were optimal and associated with complete abstinence. However, even one or two meetings per week were associated with sharp increases in abstinence. It appears that general group-therapeutic processes may be at work in 12-Step meetings, and that these have beneficial outcomes for participants. For additional information, please see Kelly, Brown, Abrantes, Kahler, and Myers (2008).

Perceptions of AA Helpfulness

Robinson presented findings on alcoholics' perceptions of AA's helpfulness, or lack thereof, from a longitudinal survey of a diverse sample of alcoholics. Participants were drawn from abstinence-based treatment programs, a moderation-based program, and individuals not in treatment. Eighteen months into the study, respondents were asked an open-ended question: “What do you think helps people deal with alcohol problems?” Responses were categorized into four initial groupings: those who said AA was helpful, those who had mixed comments about AA, those who said AA was not helpful, and those who did not mention AA. Next, these four groups were compared on demographic, clinical, and drinking outcomes.

Of 286 respondents, 42.3% found AA helpful, 18.2% had mixed comments about AA, 19.2% found AA unhelpful, and 20.3% did not mention AA. Of the demographic variables, only age was associated with group membership. Among the clinical variables, individuals with prior alcohol treatment, more drinking consequences, and more severe alcohol dependence were more likely to find AA helpful for alcohol problems. Those who identified AA as helpful and those who had mixed feelings about AA had higher percent days abstinent compared with all other groups, from baseline to 18 months. Those who identified AA as helpful and those who had mixed feelings about AA also had fewer heavy drinking days and fewer drinks per drinking day compared with those who said AA was not helpful. Those who said AA was helpful had longer duration since their last drink compared with all other groups. Those who said AA was helpful were also more likely to have attended and been involved in AA.

Study participants mentioned several qualities of the AA fellowship and the AA program as helpful, such as identifying with other alcoholics, sharing, talking, and telling stories; having a sponsor, and working the steps. Those who said AA was not helpful said they couldn't relate to others in AA groups, found there was too much negativity and complaining, or felt they could handle the problem on their own. For a more detailed description of this work, please see Robinson, Price, Kurtz, and Brower (2009).

AA Viability—Thriving Despite Challenges

White placed AA and NA in a historical context, noting there have been more than 100 mutual aid recovery groups since the 1730s. Many of these groups are thriving alongside AA and NA currently, and, in the future, more will come into existence. Threats to the early survival of AA and NA were the same threats that could undermine any mutual aid recovery group. They include leadership relapse, struggle for consensus about the program, program infidelity and instability, professionalism, issues of money, and limits of inclusion and exclusion. The rise and fall of these groups can sometimes depend on the charismatic leadership of an individual whose personality initially mobilizes and inspires many, but whose personal foibles could also undermine the organization. Other groups fail by way of entanglements related to religion or politics or stagger under challenges to the group's credibility. White talked about why AA was successful among the succession of mutual aid recovery groups. First, AA has been thriving and expanding since 1935, and membership surveys count two million members worldwide. Second, AA is accessible and available in an abundance of communities, whereas other recovery organizations may not have meetings in as many locations. Third, and most significantly, AA is unique in its 12 traditions. The 12 traditions are AA's “viable framework” for governing its “organizational life.” White quoted Robin Room, who stated that in 100 years AA may be remembered more for its traditions than its steps; its traditions have kept it from falling victim to several sources of potential destruction.

White described current trends that will shape the future of AA and NA. These trends include the varieties of recovery experience, including the varieties of 12-Step fellowships in existence for a range of addictions and the evolution of specialized meetings, such as those for doctors or musicians; recovery institution building, referring to recovery ministries and recovery grassroots advocacy movements; the professionalization and commercialization of recovery support, such as the recovery coach for hire and the growing network of government-funded peer-based recovery support organizations; and points of convergence and divergence between the science of recovery and NA and AA folklore. In a recent article, White (2010) expands on the future of AA and NA.

A Broader View of Wholeness

Nearing the day's conclusion, Kurtz reminded participants that the sciences, physical or social, are not the only means by which we achieve health and wholeness. Science discovers knowledge more by breaking down than by building up. Scientific knowledge best produces wisdom when tempered by the realization that the most precious realities escape quantification and manipulation. Love, beauty, devotion, and, yes, sobriety itself cannot be objectified without changing their nature. Not everything that counts can be counted, and the healing that involves the making whole of a life involves not seeing different things but seeing everything differently. Thus far in the human story, the open mindedness that blends scientific knowledge with recognition of the power of the arts and humanities in areas called “spiritual” has shown the greatest success in dealing with phenomena labeled “addiction.”

What We Know Now: A Summary of Knowledge Presented at the Conference

• The preponderance of evidence supports the causal pathway that AA attendance leads to abstinence (Kaskutas, Zemore).

• 12-Step affiliation significantly enhances the odds of sustaining abstinence for multiple years among polysubstance-dependent individuals (Laudet).

• 12-Step involvement yields benefits above and beyond meeting attendance (Kaskutas, Zemore, Laudet)—and this is especially important for women (Laudet).

• 12-Step attendance declines over time (Laudet, Kelly). Patterns of AA and NA attendance mirror patterns of treatment attendance with multiple stop-and-start episodes (Laudet).

• A substantial minority of recovering substance abusers in the community do not participate in 12-Step programs (Laudet).

• For adolescents, the relationship between AA meeting attendance and percent days abstinent increase in linear and positive direction at 6 months and 12 months posttreatment (Kelly).

• A combination of treatment and AA is most effective (Kaskutas, Zemore).

• Among adolescents, early posttreatment attendance, even in relatively small amounts, predicts long-term helpful outcomes. Consistent attendance over time predicts favorable outcomes (Kelly).

• Three or more AA/NA meetings per week are optimal and associated with complete abstinence. However, even one or two meetings per week are associated with sharp increases in abstinence (Kelly, White).

• Of 1.9 million people who are addicted to drugs or alcohol, only 18% are alcohol only and only 36% are drug only (White).

• Those who state AA is helpful have better drinking outcomes. Those who state AA is not helpful have poorer drinking outcomes (Robinson).

• Addiction severity predicts participation in AA and NA among adults (Robinson) and adolescents (Kelly).

• Individuals who benefit from AA identify the importance of being in a group of sober people, see AA as a source of support, benefit from others' experiences, and search for AA meetings and members with whom they find compatibility (Robinson).

Implications For Practice

• Enhance motivation for recovery and help individuals to accept support: Laudet's research found that the reasons people leave 12-Step programs are parallel to the lessons learned from relapse: one must want recovery and be willing to accept help from others. Perhaps treatment can target this parallel phenomenon by working to enhance motivation and help individuals to seek and accept support.

• Expose individuals to AA and NA: Robinson's research indicated that those who said AA was helpful had better drinking outcomes. These individuals were also more likely to have attended and been involved in AA. Therefore, AA exposure and involvement is important in allowing individuals to come to their own perceptions of AA. Those who find it helpful are likely to be helped by it.

• Hold 12-Step program meetings at on-site treatment locations: Those who attended a treatment program with an on-site meeting were more likely, after discharge, to be abstinent and attending 12-Step meetings than those whose in-house meeting had been discontinued.

• Help individuals become socialized to the AA experience: Incorporate a group designed to do just that, such as Kaskutas and Oberste's “MAA'EZ: Making Alcoholics Anonymous Easier.” This manual-based and evidence-based group designed to help individuals in treatment experience AA and overcome obstacles to experiencing the organization's benefits. The manual including the full curriculum is available from the authors. The MAA'EZ approach has been tested and evidence for its effectiveness has been published (Kaskutas, Subbaraman, Witbrodt, & Zemore, 2009).

• Encourage participation during and directly after treatment: Those who participated in 12-Step programs immediately after a treatment episode fared better over time (Kelly).

• Encourage 12-Step involvement, not just 12-Step attendance: Those who became involved in AA and NA had more stable abstinence than those who merely attended. Doing service for the group and having a home group are especially important (Laudet).

• Encourage a minimum of three meetings a week: Three meetings per week is the optimal pattern of attendance that predicts abstinence among adolescents, but lesser participation is also extremely helpful (Kelly).

• Become knowledgeable about the variety of mutual aid recovery groups in the community: Become familiar with different types and varieties of AA meetings and encourage clients to try several meetings before coming to definitive conclusions about their options (Robinson).

Future Research

Laudet's research identified a number of forms of 12-Step participation that were predictive of good outcomes. For example, doing service and socializing with others who are in recovery predicted sustained abstinence. Research is needed to test whether correlates of these activities can be helpful to those who choose not to identify with 12-Step programs. For example, among individuals who do not go to 12-Step meetings, can volunteer work be substituted for 12-Step service as a helpful agent of change?

White's work reveals a historic trend toward recovery rather than pathology. However, research is needed on long-term recovery. What is the lived experience of individuals with decades of recovery? What do they have to share that can be helpful to multiple stakeholders?

Does court-mandated AA attendance work? Would judges broaden their definitions of acceptable mutual help groups beyond AA? Are online meetings effective, and could these be recommended to individuals hesitant to try face-to-face groups?

There is a paucity of research on older adults and 12-Step participation. How effective are AA and NA for this population?